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Retinal Physician

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Advances in Training for Vitreoretinal Surgery in the Digital Era

New options continue to enhance learning.

By: Jonathan B. Lin, MD, PhD, John B. Miller, MD, Demetrios G. Vavvas, MD, PhD
Retinal Physician July 1, 2023 Vol 20, Issue July/August 2023 Page(s): 30-32

From the Archives

Vitreoretinal surgery is highly technical, with a steep learning curve. Historically, training vitreoretinal surgeons has relied primarily on an apprenticeship model whereby trainees learn from experienced surgeons with graduated autonomy, following the adage, “See one, do one, teach one.” Although this approach is effective and still a core component of modern surgical teaching, many new educational resources have been developed to supplement learning in the operating room. Here, we discuss some of these new resources and speculate how they will likely continue to improve vitreoretinal surgery education in the coming years.

VITREORETINAL SURGICAL SIMULATORS

Simulators allow beginning surgeons to practice surgical steps with lifelike surgical instruments in a low-stakes environment without any risk to patients. One common ophthalmic surgical simulator is the Eyesi Surgical System (Haag-Streit Simulation). This system includes a mannequin head with a model eye, various instruments that mimic real surgical instruments, and an operating microscope controlled with a foot pedal (Figure 1). Eyesi is well known for its use in teaching cataract surgery, but it also offers a vitreoretinal interface set with an Oculus SDI/BIOM mimic that functions similarly to the BIOM used in the operating room. This vitreoretinal interface set allows trainees to go through vitreoretinal surgery–focused training modules, including those simulating posterior hyaloid detachment, peripheral vitrectomies, internal limiting membrane (ILM) peeling, removal of epiretinal membranes (ERM), and treatment of retinal detachments with oil or gas endotamponade. Importantly, the Eyesi tracks the movements of the surgical instruments and monitors other parameters, such as presence of hand tremor and/or hand pressure. After completing each module, trainees receive performance metrics based on target achievement, efficiency, instrument handling, microscope handling, and tissue treatment. Newer models of the Eyesi also incorporate a 3-dimensional (3D) heads-up display to simulate modern digital surgical platforms, while also allowing teachers to more directly observe trainees and enabling multiple learners to observe the training session.

Figure 1. Model eye and mannequin head used for Eyesi surgical simulation (A) and demonstration of its use (B, C), allowing surgical teaching without risk to patients.
Figure 1. Model eye and mannequin head used for Eyesi surgical simulation (A) and demonstration of its use (B, C), allowing surgical teaching without risk to patients.

Prior work by our group at Massachusetts Eye and Ear has confirmed the value of the Eyesi for teaching phacoemulsification: success on the Eyesi early in residency can predict total cataract surgery numbers.1 Although we and others have reported the value of the Eyesi for phacoemulsification/cataract extraction,1,2 there is less published information about using Eyesi to teach vitreoretinal surgery. Rasmussen et al performed a systematic review to evaluate simulator-based training in vitreoretinal surgery and, based on findings from 6 published studies, reached the conclusion that the Eyesi can possibly be used to assess and to teach skills relevant to vitreoretinal surgery.3

One limitation of simulator-based training is that the simulator instruments cannot provide tactile feedback to the operator. Some new simulators seek to address this limitation. The MicroVisTouch Simulator (Immersive Touch) has been used predominately in other surgical fields and for teaching cataract surgery. It is fully virtual, and its main advantage over other simulators is that it can provide haptic/tactile feedback. Kozak and colleagues reported that it is possible to customize this platform and integrate optical coherence tomography scans from actual patients to simulate ERM and ILM peeling.4 They reported that this yielded a more realistic simulated surgical experience, although it appears to require significant customization and technical expertise. Finally, model eyes are available commercially from Phillips Studio with materials designed to behave similarly to human tissue when performing trocar placement and scleral buckling. These model eyes do allow for practice of surgical maneuvers, but they do not fully recapitulate the behavior of human tissue. All in all, no simulation can replace time spent learning in the operating room, but simulation can help build basic skills and reinforce important principles for budding vitreoretinal surgeons.

ONLINE SURGICAL VIDEOS

There is no replacement for hands-on surgical training with simulators or in the operating room, but reviewing surgical videos from other surgeons can also aid trainees in understanding the nuances of vitreoretinal surgery and gaining exposure to various surgical techniques. Surgical videos have long been presented and discussed at meetings, and now the availability of these videos in accessible online repositories has facilitated their widespread utilization. For example, the American Society of Retina Specialists and Vit-Buckle Society both host online databases of vitreoretinal surgical videos (available at asrs.org and vitbucklesociety.org ). Currently, these videos cover a breadth of topics, including intraocular lens, macular surgery, retinal detachment, retinopathy of prematurity, uveitis, diabetic vitrectomy, and vitrectomy. Another excellent resource is the online textbook titled “Vitreoretinal Surgery Online” (vrsurgeryonline.com ), which was created by Dr. Adrian Fung. This is an updated version of the textbook “Vitreoretinal Surgery for Trainees,” and it has been made freely available online to anyone worldwide. There are many other good surgical video teaching platforms, such as those archived from prior Alcon Retina Film Festivals, VR Pro, and Alcon’s Surgical Retina Digital Portal. Importantly, the surgical videos in these resources have been vetted by experts in vitreoretinal surgery and are therefore of consistently high quality, unlike some videos that are available on websites such as YouTube.5

NEW PLATFORMS FOR SURGICAL VISUALIZATION

There have also been advances in visualization systems for vitreoretinal surgery that may offer some advantages to facilitate surgical teaching. For example, the Ngenuity Visualization System (Alcon) is an example of a 3D heads-up visual display system that uses a high dynamic range camera to project overlapping images of the operating field on a large display.6 Stereopsis is achieved with polarized eyeglasses that can be worn by the surgeon, as well as other trainees and observers in the operating room. There are similar systems available from other manufacturers, including the Artevo 800 system (Zeiss) and Beyeonics One (Beyeonic Vision).

In addition to providing improved ergonomics by allowing surgeons to maintain a normal, face-forward posture, Ngenuity provides the same stereoscopic view for all individuals in the operating room wearing polarized glasses. This is different than a conventional viewing system, which has a primary operating microscope for the surgeon and 1 to 2 side scopes for the assistants/observers; while other observers can view the surgery from display monitors, they cannot view the surgery in stereo. When using Ngenuity, surgical teachers can more easily point out important landmarks or guide the trainee during surgical maneuvers with arrows/pointers on the display screen rather than relying on verbal instructions. This platform can also be used to more easily teach less common procedures, such as scleral buckling.7 We previously found that trainees, especially those earlier in their training at the medical student or ophthalmology resident level, tended to feel that using Ngenuity for vitreoretinal surgery improved their educational experience.8 Importantly, research has shown that heads-up visualization is not associated with worse outcomes when used for retinal detachment repair, vitrectomy for ERM, or scleral buckling compared with conventional approaches.7,9,10

TELEMENTORING

The 3D digital surgical video of Ngenuity also allows for a superior telementoring experience like nothing that was previously available. Our group previously demonstrated that it is possible to live stream 3D surgical video from our surgical center over the Verizon 5G network to the Verizon headquarters in Cambridge, Massachusetts.11 We have subsequently been able to live stream over our local hospital network with a plug-and-play device. In a multicenter study, we showed additional evidence for telementoring capabilities with external live streaming in both 2D and 3D over Zoom to a laptop and a virtual reality (VR) headset.12

NEW PLATFORMS FOR MEETINGS

There has also been increased interest in virtual meetings in the Metaverse: a virtual 3D space with participants often using VR or augmented reality (AR) headsets.13 These virtual environments combine the advantage of being able to invite participants from across the world with the ability to interact with other individuals in the virtual space, much like you might at an in-person event. Metamed is a pioneer in this technology. At Massachusetts Eye and Ear, we have hosted several surgical retina conferences and lectures in the Metaverse and, to the best of our knowledge, we are the first to host in the Metaverse (1) a local surgical conference at a single academic institution; (2) an international joint surgical conference with Mexico City; and (3) a retina residency lecture by Dr. John B. Miller in the Harvard Ophthalmology Lecture Series (Figure 2). These virtual meeting spaces have allowed us not only to invite guests from across the world but also to review recordings captured from the 3D platforms described above. These virtual platforms supplement the in-person vitreoretinal surgery courses that are held around the country, for example, at Massachusetts Eye and Ear (eye.hms.harvard.edu/vrcourse ), at Duke University (asrs.org/education/calendar/event/6526/9th-annual-duke-retina-fellows-advanced-vitreous-surgery-favs-course ), and sponsored by Alcon (alconexperienceacademy.com ).

Figure 2. Screenshot showing Dr. John B. Miller teaching about a case at a recent Massachusetts Eye & Ear/Harvard Ophthalmology surgical conference that was held in the Metaverse
Figure 2. Screenshot showing Dr. John B. Miller teaching about a case at a recent Massachusetts Eye & Ear/Harvard Ophthalmology surgical conference that was held in the Metaverse

CLOSING REMARKS

Vitreoretinal surgery is difficult to learn. There is no replacement for learning in the operating room, but there have been numerous technological advances over recent years, including vitreoretinal surgery simulators, online repositories of surgical videos, advances in surgical visualization systems, telementoring, and new platforms for educational meetings. These and other future innovations will continue to enhance vitreoretinal surgical education. RP

Jonathan B. Lin, MD, PhD, is an ophthalmology resident in the retina service of the department of ophthalmology at Massachusetts Eye and Ear and Harvard Medical School in Boston. He reports no relevant disclosures. John B. Miller, MD, is director of retinal imaging and associate director of the vitreoretinal surgery fellowship at Massachusetts Eye and Ear and an assistant professor of ophthalmology at Harvard Medical School. He reports consultancy to Alcon and Zeiss. Demetrios G. Vavvas, MD, PhD, is director of the retina service at Massachusetts Eye and Ear and the Solman and Libe Friedman Professor of Ophthalmology at Harvard Medical School. He reports no relevant disclosures. Reach Dr. Miller at john_miller@meei.harvard.edu. Editor’s note: Hear discussion of this article at retinapodcast.com .

REFERENCES

  1. Roohipoor R, Yaseri M, Teymourpour A, Kloek C, Miller JB, Loewenstein JI. Early performance on an eye surgery simulator predicts subsequent resident surgical performance. J Surg Educ. 2017;74(6):1105-1115. doi:10.1016/j.jsurg.2017.04.002
  2. Lin JC, Yu Z, Scott IU, Greenberg PB. Virtual reality training for cataract surgery operating performance in ophthalmology trainees. Cochrane Database Syst Rev. 2021;12(12):CD014953. doi:10.1002/14651858.CD014953.pub2
  3. Rasmussen RC, Grauslund J, Vergmann AS. Simulation training in vitreoretinal surgery: a systematic review. BMC Ophthalmol. 2019;19(1):90. doi:10.1186/s12886-019-1098-x
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  10. Zeng R, Feng Y, Begaj T, Baldwin G, Miller JB. Comparison of the safety and efficacy of a 3-dimensional heads-up display vs a standard operating microscope in retinal detachment repair. J Vitreoretin Dis. 2023;7(2):97-102. doi:10.1177/24741264221150074
  11. Lu ES, Reppucci VS, Houston SKS, Kras AL, Miller JB. Three-dimensional telesurgery and remote proctoring over a 5G network. Digit J Ophthalmol. 2021;27(3):38-43. doi:10.5693/djo.01.2021.06.003
  12. Seddon IA, Rahimy E, Miller JB, Charles S, Kitchens J, Houston SK. Feasibility and potential for real-time 3D vitreoretinal surgery telementoring. Retina. 2022;10.1097/IAE.0000000000003656. doi:10.1097/IAE.0000000000003656
  13. Ong J, Hariprasad SM, Chhablani J. Into the RetinaVerse: a new frontier of retina in the metaverse. Ophthalmic Surg Lasers Imaging Retina. 2022;53(11):595-600. doi:10.3928/23258160-20221017-01

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